Patient Warming’s Powers in SSI Prevention

This important safety measure is much more than a simple patient-pleaser.

Patient warming stories tend to focus heavily on the “comfort” factor. That makes sense when you hear about all the positive comments and high satisfaction scores that tend to come from patients who felt snug and toasty throughout their entire perioperative journey.

While patient satisfaction may be a sexier “hook,” patient safety is the top priority of patient warming. After all, if you don’t keep patients safe, you certainly won’t keep them satisfied.

That’s why it’s important to keep health benefits at the forefront of the patient warming conversation. Inadvertent perioperative hypothermia, a common issue during elective surgery, increases the risk of surgical site infections (SSIs). A standardized warming protocol reduces that risk and offers the coveted ancillary benefits that bolster survey scores.

“It is true that many people think of warming as a patient satisfaction issue, but the truth is we know that mild perioperative hypothermia triples the risk of SSI,” says Lisa York, MSN, RN, CASC, CAIP, executive director for the Hunterdon Center for Surgery in Flemington, N.J. “Even in minor surgery, there is an SSI risk if thermoregulation is ignored. For our patients who go home the same day, the symptoms may develop later.”

Ms. York presents a simple but compelling argument for patient warming. “Warming is easy, evidence-based and affordable,” she says. “It is something we should do for our patients routinely.”

Getting from Point A to Point B — and bringing your entire staff along for the ride — is the challenge.

From start to finish

For every facility, the journey to make warming a priority is different, but there are common elements. Most leaders who find a way to make this safety practice a priority will say that warming should be performed throughout the entire perioperative process, as opposed to only intraoperatively.

How much of a difference can pre-, intra- and post-op warming measures make in reducing infections? If you ask Heather Kooiker, DNP, MSN, RN, CNL, CNOR, CRNFA, assistant professor of nursing and surgical immersion program manager at the College of Health Professions-Davenport University in Grand Rapids, Mich., it can make a lot of difference.

At a previous full-time clinical role, Dr. Kooiker’s hospital had a significant issue with post-op infections in patients who underwent colon procedures until it took certain steps, including prewarming.

“We instituted a colon bundle that included prewarming patients for at least 30 minutes, and SSIs in these patients dropped significantly,” Dr. Kooiker wrote in OSM. “The results were so good that by the time I left, the hospital was considering prewarming all surgical patients.”

“Warming is easy, evidence-based and affordable. It is something we should do for our patients routinely.”
—Lisa York, MSN, RN, CASC, CAIP

A big part of the success Dr. Kooiker’s former facility experienced stemmed from what it did before the procedure began. She advises leaders to always start warming efforts in pre-op — and to offer compelling reasons for staff and leadership to buy in to the practice.

“Patients’ core temperatures often drop from the time they leave pre-op to the time they’re positioned on the OR table,” she wrote. “There are multiple reasons for this, including the fact that many facilities still use warmed cotton blankets instead of active warming measures.”

Things only get worse once patients are in the OR, a room that’s significantly colder, and they’re wearing nothing but a gown.

Dr. Kooiker says active warming does a much better job of keeping patients’ core temperatures at the preferred 36°C than cotton blankets, which are better at maintaining patients’ surface temperatures than their core ones.

“An active warming protocol is better suited to maintaining patients’ internal temperatures, which is what matters when it comes to infection prevention,” she wrote. “Prewarming helps to ensure patients are able to remain normothermic once they enter the cold OR environment. Maintaining normothermia is important in all three phases of care, but it all starts in the pre-op bay.”

Devil’s in the data

If you really want to garner support for a comprehensive, standardized patient warming protocol, any data you can provide upper management on the correlation between increased SSIs and unwarmed patients can prove invaluable. Dr. Kooiker urged facilities to perform root-cause analyses on SSI cases and show leadership that perioperative hypothermia was likely the culprit whenever possible.

“Show them national research and recommendations about evidence-based best practices that recommend all patients be warmed in some fashion, and then extol the virtues of active warming — from pre-op through post-op — as it pertains to maintaining core temperatures,” she wrote. “Then remind them that hypothermia is attributed to poor outcomes that are non-reimbursable.”

Dr. Kooiker used the example of CMS reimbursement, which is tied to hospital-acquired conditions due to hypothermia such as SSIs, pressure injuries, periop hemorrhage or hematoma, post-op sepsis and wound dehiscence.

A call to ASCs

The importance of patient warming has certainly grown over the last decade, but there’s still a long way to go, particularly in the ASC sector.

“We need to really make it an initiative in the ASC space, simply because patients are not usually undergoing longer procedures and the idea that it isn’t really going to make a difference seems to be the deterrent,” says Ms. York. “I have seen the warming machines used for longer cases but not that frequently for the quicker ones.”

Keeping patients warm, however, is one of the best ways to prevent hypothermia and subsequent SSIs. Active warming is worth investigating. OSM